Practical Approaches to Achieving Quality, Safety, and ...
Transcript of Practical Approaches to Achieving Quality, Safety, and ...
Practical Approaches to Achieving
Quality, Safety, and Population Health
April 17, 2017
Kenny J. Cole, MD, MHCDS
Chief Clinical Transformation Officer
Baton Rouge General Medical Center
Why Hospitals Should Fly
5
Fictional book
Describes a hospital
where high reliability
has already been
achieved, which hasn’t
yet become a reality
Transformation
StrategyOrganizational
StructureCulture
How Hospitals Can Fly
Data & Analytics
Measured Results
Processes
Outcomes
Craft-based vs. Lean Production
Sequential vs. Iterative Care Processes
Southwest Airlines
7
Only commercial airline to win the “Triple Crown”
Secret Sauce: Relational CoordinationShared Goals
Shared Knowledge
Mutual Respect
“Culture is what you do
when no one is looking.” - Herb Kelleher, CEO of Southwest Airlines
BRG Transformation Plane
Vision: We will heal, lead, and inspire communities to live the healthiest lives possible.
Level of Risk for Harm
Unsafe Very Safe
Being in
a
Hospital
Base
Jumping
Hang
Gliding
Para-
chuting
Taking
a Drive
Going
for a
Walk
Flyingon a
Commercial
Airline
Learning to FlyHigh
Reliability
Why the need for High Reliability?
Number of Deaths per Year Associated with
Preventable Harm in Hospitals
2000: Up to 98,000 2013: Up to 400,000
James, John. A New Evidence-based Assessment of Harms Associated with Hospital Care. J Patient Saf;9:122-128
Kohn, Linda T, Janet Corrigan, and Molla S. Donaldson. To Err Is Human: Building a Safer Health System. Washington, D.C: National
Academy Press, 2000. Print. 11
High Reliability Organizations
A high reliability organization (HRO) is an
organization that has succeeded in avoiding
near accidents and catastrophes in an
environment where normal accidents can be
expected due to risk factors and complexity
Many organizations and even a few industries
have achieved high reliability
• Healthcare is NOT one of them
• Commercial Aviation IS
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Low Reliability vs. High Reliability Low reliability organizations dismiss the regular
chatter of imperfect processes as unavoidable noise
High reliability organizations recognize that complex
systems are imperfect and prone to mistakes and defects
When operations of high reliability organizations speak
up—in the language of problems or unexpected
outcomes—they stop the line, listen, communicate,
collaborate, learn, innovate, and IMPROVE—
propagating what is learned in one situation to have
maximum impact throughout the organization
13
High Reliability organizations
continually improve and advance
their expertise
The Launch of High Reliability Teams
BRG’s Mission
“We Create Exceptional
Experiences and Value
for the People We
Serve, Through Health
and Healing”
Every department has a HRT team Clinical and Non-
clinical
Identified 70 HRT Champions from the front line to lead the teams
Training Started in March 2016 and all 70 have ben trained
Early Wins
Values Excellence an allegiance to
the relentless pursuit of
perfection, we individually and
collectively demonstrate
expertise, innovation, and
accountability in all that we do
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Stop the Line Kudos to Lakisha Dunn, RN who recognized that
D5W was hanging with the unit of blood instead
of saline; and STOPPED THE LINE!
Compatible solutions with blood products 5% Dextrose in water causes hemolysis
Storage: Found D5W mixed up with Saline products
Staff Hurried: Grabbed from where D5W is
normally stored without really looking at the
at the label closely
Realized that the staff needed a
Visual Cue and a 5-S
April 12, 2016 The Actual Tubing
Learning to Fly – MACULessons Learned: Blood Administration
High Reliability Organizations (HRO)
High reliability organizations Interpret
deviations and departures from prediction as
important signals—not noise
Low reliability organizations manage functional
specialties in silos
HRO leaders invest continually in the integration
of specialties into a process in order to learn
and create new knowledge
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Learning to Fly: B5, ICU, CT, PharmacyLessons Learned: Teamwork
For the end result to happen perfectly,each member of the team:
- Knew their role- Executed their assignments - perfectly- Didn’t pass on defects
May 24, 2016
Becoming a High Reliability Organization
Idiosyncratic confluences and coincidences of people,
processes, products, places, and circumstances can create
a hazardous situation where none had been known to exist
No team can design a perfect system in
advance, planning for every contingency and
nuance
BUT…people can discover great systems and
keep discovering how to make them better
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Chasing ZeroIt’s NOT about a surveillance program to
monitor for infections.
It IS about a high reliability culture
that’s constantly…
Obsessed with preventing defects
Continuous improvement
Catching near misses19
Culture
Change
• Goal :To increase hand-hygiene
practices of our staff and any other
staff member that enters our
patients’ room. To also hold each
other accountable for adhering to
cleaning hands prior to providing
care to hour patients
• Problem Statement: Hospital
staff have not embraced proper
hand hygiene practice prior to
patient care. B3 has had two
nosocomial infections of c-diff for
quarter 4-2015 and quarter 1&2 of
2016
•
HRT Summary of OpportunityHRT Champion: Lakisha Dunn
HRT Coach: Rochelle Howard Unit: B3
Executive Sponsor(s): Denise Bradford Hand Washing
Opportunity/Goal Team Members Shared Tools Used
Improvements Improved Key Metric Project Benefits
Team Members: Lakisha Dunn RN, Savanah
Creaghan RN, Sonya Bourgeois, Martha
Scott PCA, Jessica Smith RN, Rochelle
Howard, MSN, Dr. Raju
(some members not pictured)
Physician Champion: Dr. Raju
• Secret Shopper Audit
• Video
Signage is a good visual tool, but is often overlooked and can become part of the background in a hospital. Information that is repeated is usually more effective.
Nursing staff presents the tent card to patients on admit as part of AIDET.
The tent card is signed by the nursing staff.
Hand Hygiene is discussed during huddle with MD and nursing staff to make hand hygiene a priority
Secret Hand Hygiene Shopper is performed monthly, including staff name and compliance and placed on bulletin board.
Note: For the months of Jan-Feb, no
intervention was performed prior to survey
No survey performed May/June
0
50
100
Nurses Doctors
HCAHPS Survey Results of Staff washing/sanitizing their hands
June July August
Progress of HRT Teams form June to Jan 2017
Projects to Date
Completed Projects-
22
Projects actively in
Progress- 21
Projects identified and
teams started- 12
Physicians- 4
Coaches- 55
Champions- 55
Front Line- 288
Involvement
The 4 Capabilities of HRO’sCapability 1
Seeing problems as they occur
Strong leadership
Create a deliberate effort to
create urgency around seeing
and solving problems
Convey urgency and accuracy
of reported information
Front line staff
bringing ideas for
improvements
through emails,
surveys, posters in
lounges, staff
meetings & unit
huddles
Lean concept of
Visual Management
Early Wins
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Understanding Failure to Rescue? Failure to recognize clinical deterioration
Failure to communicate and escalate concerns
Failure to physically assess the patient
Failure to diagnose and treat appropriately
Success depends on astute bedside care,
as well as vigilance in patient
assessment, to detect changes that could be a sign
of impending critical event.
April 26, 2016
Learning to Fly – Speech TherapyLessons Learned: Assessment
Huddle Boards
• Problem Statement: Nursing staff
encounter issues that arise
throughout each shift on a daily
basis and solve problems in isolation
and/or encounter recurring issues.
• Goal: Provide staff with a Huddle
Board as a mechanism for staff to
identify safety concerns and
opportunities for improvement as
they arise, offer suggestions for
improvement on a daily basis,
prioritize and solve problems, and
share the knowledge.
HRT Safety Huddle BoardHRT Champion: Lakisha Dunn
HRT Coach: Rochelle Howard Unit: General Surgery PTA4
Executive Sponsor(s): Denise Bradford Name of Project: Safety Huddle Boards
Opportunity/Goal Team Members Shared Tools Used
Improvements Improved Key Metric• Empowers staff
• Encourages everyday improvement
from all employees
• Builds a culture of safety and
continuous improvement
Project Benefits
• Opportunity/Suggestion Cards
• Daily discussions (huddles)
using board which consists of
4 main sections:
New Improvement
Opportunities
PICK Chart
Works in Progress
Improvement Ideas
Implemented
• Signal (identify problem), Swarm,
Solve, Share
• PICK Chart
• Cherita Washington, RN
• Breona Sands, Unit Clerk
• Arian Snell, RN
• Key Metrics – we expect to see
improved employee engagement
scores and patient safety
• Huddle Board has provided staff
with a structured approach for daily
problem solving and resolution of
problems.
• 2 issues/suggestions have been
resolved via a “Just Do It” approach
while others will require a HRT
project
The 4 Capabilities of HRO’sCapability 2
Swarming and solving problems as
they occur
Go through a disciplined cycle
of real-time problem
recognition, diagnosis (root-
cause analysis), and treatment
It is the disciplined use of
process improvement tools
Each HRT Champion
attended a 4 hour
workshop learn tools
to be able to solve in
a systematic fashion
Connecting the dots
with methodologies
used at BRG
Early Wins
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LEAN
TeamSTEPPS
The 4 Capabilities of HRO’sCapability 3
Spreading new knowledge
Coping, firefighting, and making do are
gradually replaced throughout the
organization by a dynamic of
identifying opportunities for process
and product improvement
As opportunities are identified and the
problems are investigated, pockets of
ignorance are converted into nuggets
of knowledge
Excel spreadsheet to share the
new knowledge to other units that
would benefit from the
improvements learned
OPSOC presentations by front line
Early Wins
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The 4 Capabilities of HRO’sCapability 4
Leading by Developing Capabilities
1, 2, & 3
Expect leaders at all levels to
develop the organization’s ability
to manage work in such a way as
to see problems, solve problems
where they were seen in order to
build new knowledge to be
useful throughout the organization
Directors/ managers
making it possible for
front line staff to
attend HRT meetings
Early Wins
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Cath Lab EventsIssues
1st critical event
occurred-
Over dosing of
patients from weight
error
2nd critical event
occurred
Incorrect dosing chart
used
Hospital effort to improve
weighing of patients
Cath LAB added double
verification of patient weight
Dosing charts made for 2
drugs commonly used
Cath Lab HRT placed mistake
proof concept to prevent from
occurring again
Continuous improvement….
Solutions
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Learning to Fly: Cath LabLessons Learned: Reason’s Swiss Cheese Model
High Reliable Organizations
Preoccupied with Failure
“Every step in a process
has the potential for failure.
The ideal system is
analogous to a stack of
Swiss Cheese slices; where
the holes are opportunities
for failure.
The layers are defensive
mechanisms to catch the
error.”
- James Reason
Error is NOT caught; reaches patient
Good Catch; line stopped; No Harm
September, 22, 2016
Cath Lab HRTCath Lab HRT Members Solution
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• Cath Lab Tech- HRT Champion
• Cath Lab Manager- HRT Coach
• Team members, 3 Cath Lab RNs
and a pharmacist
• Medication kits were made in advance which
included: drug, dosing chart and supplies
• Each bag was color coded and laminated
dosing chart which matched the bag were
included in each bag
• Since these medications are need quickly,
they can grab the bag and everything is there
to safely administer medication
Early Wins
Arts and Medicine identified an opportunity to
assure musical instruments, art supplies and
other items brought in and out of patient rooms
were cleaned between patients. They now have
a new process in place
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They submitted their project
to the National Organization
for Arts in Health (NOAH) for
possible inclusion in their
“State of the Union” at their
first conference this fall
Team Members ICU Nurses: Laken Cook, Emily Galjour,
Emily Harrington, and Mallory Price
Physical Therapy: Rachael Feirman
Wound care: Laura Hodges
PCAs: Kay Stewart, Marshall Wheeler
Dietary: Chuck Mouton
Physician Champion: Dr. Godke
HRT Facilitator: Darcy Stafford
Solutions Team Working On Audited documentation of turns and current
prevention protocol compliance
Preventative sacral dressing placed on all at risk patients
Trialed and ordered repositioning device with fluidized positioner (the Tortoise)
Reinforced use of heel protection boot
Encouraged skin assessment at change of shift with bedside handoff
Results: ICU acquired PI rate from June-December decreased to 4.14 per 1000 patient
days from 11.12 in Q1-Q2 of 2016.
Problem Statement
Goal Statement Our goal is to decrease the
incidence of non-device-related ICU acquired pressure injuries from 11.12 per 1000 patient days (Q1-Q2 2016) to below national average (8.8-10.3/1000 pt days) by December 31, 2016.
HRT Summary of OpportunityHRT Champion: Meredith Cooper
HRT Coach: Jobe Nasca Unit: ICU
Executive Sponsor(s): Robin Passman Name of Project: Pressure Ulcer Prevention in the ICU
The ICU acquired pressure injury (PI) rate increased dramatically from October 2015 to April 2016 to a rate of 11.12/1000 patient days (total of 42 pressure injuries)
Impact: Patient and family distress; decreased
satisfaction with care
Extreme pain to patient
Caregivers expressed feeling of inadequacy of care provided
Negatively affects staff morale
Increased cost of care as the average cost of treatment for a Stage II Pressure Injury ~$10,000
Congratulations to Units with:ZERO HARM October & November: A4, B5, GERI
ZERO HARM AUG, SEPT, OCT, NOV: A3, B3, SNF, Rehab
16
7 7 6
1 1 102468
10121416
SSI CAUTI CDIFF MED ERROR >=4 PE/DVT Pressure Ulcer CLABSI
FY'17 Harm by Type(August - November, 2016)
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Near Misses and Zero Harm
Celebrating our pursuit of High Reliability
Last but not least we are now
rewarding and recognizing our
front line staff for the part they play
Culture Change
Helping us to achieve a “just culture” by
Empowering front line to stop the line when they see near
mishaps
Involving front line staff to come up with solutions to prevent
from happening again
We now have a more transparent culture
Sharing mishaps so staff is aware we have opportunities for
improvement
Has truly created an excitement in the front line staff- We
receive phenomenal comments on survey from HRT
workshop- “Loved explanation of HRTs and realized how
important it is to “chase zero”
Helping to eliminate the “we- they” culture
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What’s Value?
Quality of outcomes that matter to
patients and payers
Cost of delivering those outcomes
How to Create Value?
Care Model Redesign
Population Health Primary Care
Care, Case, & Disease Management
Utilization Management
Elimination of Unnecessary Imaging, Procedures, & Surgeries
Site of Service
More Expensive Less Expensive
Inpatient Outpatient
Lower Per Capita Costs
We Create
Exceptional
Experiences and
Value for the
People we Serve
Clinical Transformation
Hospitals
Specialists
Primary
Care
Hospitals
Specialists
Primary Care
Fee-for-ServicePay-for-
PerformanceShared Savings Capitation
Bundled Payments
Volume Value
RevenueCenter
Acute Care Feeders Population Health
Supply Sensitive Care 60%Preference Sensitive
Care 25%Effective Care 15%
-5 – 10 yrs
MARKET POWER VALUE = QUALITY COST { {
CostCenter
RevenueCenter
CostCenter
{{ {
Percentage for total cost of care for Medicare Spending
Sum total of improved
individual outcomes
Reduced complications of
chronic disease
Greater percentage of
people receiving up-to-date
evidence-based care
Fewer potentially
preventable ER visits and
admissions
Proactive patient outreach
and patient engagement
Improved patient experience
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Population HealthPo
pu
lati
on
Hea
lth
Redesigned Primary Care
More Reliable Systems and Processes
Robust Care Coordination
New financing mechanisms
Infrastructure investment
VALUEPHYSICAN
ALIGNMENTMARKET GROWTH
Clinical Integration
Quality of outcomes
that matter to
patients and payers
Quality of outcomes
that matter to
physicians and payers
Volume Through Value
Predicting ACO/CIN Failure
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1. Persistence of fee-for-service reimbursement >>> fee-for-
value as the predominant source of revenue for network
2. Wrong staffing model with poor PCP-to-specialist ratio
3. Failure to adopt comprehensive integrated population
health focused IT platform
4. Lack of physician leadership and management (who
understand value)
5. Failure to redesign primary care to effectively and
efficiently manage population health
6. Large hospital systems that have traditionally relied on
market power
Failure to Create Value
Failure to Create Value
Predicting ACO/CIN Failure
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7. Failure to adequately invest in the appropriate
infrastructure design
8. Provider culture habituated to fee-for-service payment
9. Patient culture habituated to being passive consumers of
healthcare (lack of consumerism)
10. Entrenched provider and patient culture with fixed
mindsets that more care is better
11. Failure to corral unwarranted variation and control
excessive utilization
12. Failure to overcome inertia